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1 Korean Journal of Clinical Psychology Vol. 36, No. 3, Original Article 2017 Korean Clinical Psychology Association eissn X The Effects of Trauma and Intrusive Rumination on Posttraumatic Stress Disorder Symptoms: The Moderated Moderated Mediation of Future Prospective Cognition and Gender Difference Ye-Seul Kim Jong-Sun Lee Department of Psychology, Kangwon National University, Chuncheon, Korea The purpose of the present study was to examine whether intrusive rumination mediated the relationship between trauma and Posttraumatic Stress Disorder (PTSD) symptoms and if negative prospective cognition moderated the mediating effect of intrusive rumination in the relationship between trauma and PTSD symptoms. In particular, we aimed to investigate whether there would be a gender difference in the aforementioned moderated mediation. A total of 440 Korean undergraduate students and graduate students were asked to complete the Life Event Checklist, Impact of the Event Scale-Revised, Event Related Rumination Inventory, and the Prospective Cognition Questionnaire for this research. The main findings were as follows: Firstly, intrusive rumination partially mediated the relationship between trauma and PTSD symptoms. Secondly, negative prospective cognition moderated the mediating effect of trauma on PTSD symptoms via intrusive rumination. Finally, there was a gender difference in the moderating effect, confirming a moderated moderated mediation. More specifically, the moderated mediating effect was observed in female students but not in male students. In conclusion, after trauma, female students who recognize the future negatively are more susceptible to PTSD symptoms through the intrusive rumination, while female students who recognize the future less negatively can be protected from PTSD symptoms under the same condition. Based on these results the implications and limitations of this study are discussed. Keywords: trauma, intrusive rumination, posttraumatic stress disorder symptoms, negative prospective cognition, moderated moderated mediation 지진을포함하여갑작스러운죽음, 심각한부상, 성폭력, 전쟁, 신체 적폭력, 자연재해혹은인재 ( 人災 ), 교통사고, 납치, 인질, 테러공 격, 고문등과같이삶에서불시에일어나는충격적이고생명을위 협하는다양한사건을미국정신의학회의정신장애진단및통계편 람 (Diagnostic and Statistical Manual of Mental Disorders, DSM- 5) 에서는외상사건 (trauma) 으로정의한다. 또한이와같은외상사 건을직접경험하거나, 타인에게일어난것을목격한사람들중외 Correspondence to Jong-Sun Lee, Department of Psychology, Kangwon National University, 1 Kangwondaehak-gil, Chuncheon, Korea; jongsunlee@kangwon.ac.kr Received Apr 19, 2017; Revised Aug 17, 2017; Accepted Aug 17, 2017 This study was supported by 2016 Research Grant from Kangwon National University. 상과관련된특징적증상들이한달이상지속되고현저하게기능이저하되는경우에는외상후스트레스장애 (Posttraumatic stress disorder, PTSD) 로진단받을수있다. PTSD의증상은외상과관련된자극의회피, 재경험, 과각성및인지와감정의부정적변화로크게네가지로나눌수있으며그외에도기억상실이나자살사고와같은다양한증상들이나타날수있는데, 증상의발현종류나여부는개인차가있으며, 보통 2개이상의증상들이혼합되어나타나는양상을보이고, 개인에게증상이나타나는기간역시 3개월부터 50 년까지다양하다 (American Psychiatric Association, 2013). 그렇지만외상사건을경험한모든사람들이 PTSD로진단되지는않으며대부분의사람들이시간이지나면서외상의영향으로부터점차회복되는것과달리, 간혹 10-30% 정도의사람들은외상과관련된증상들을지속적으로호소하는데 (Cusack, Grubaugh, 325

2 Kim and Lee Knapp, & Frueh, 2006), 이처럼외상을경험한사람들중 PTSD로진단받을수있는가능성이큰집단을위험군으로칭한다. 위험군에는다양한집단이해당될수있으며그중하나가대학생이될수있는데, 이는다른연령대에비해 20대초반에서 PTSD로진행될가능성이높으며심각한외상사건에비교적노출되기쉬운시기때문이라고볼수있다. 이를뒷받침하는자료로써 DSM-5에서는여성및젊은연령이외상전위험요인이될수있다고기술하고있으며, 2011년도보건복지부가성인인구 6,000명을대상으로실시한정신질환실태조사에따르면, PTSD 발병율이 20대에서가장높았다. 외상에노출된많은대학생들이다양한증상들과일상생활기능의저하로고통받고있다는사실은연구를통해꾸준히보고되고있다. 가령, 대인간외상을경험한대학생들을대상으로한국내연구에서는이들이타인과친밀해지는것에대한두려움을경험하여대인관계능력에손상을보인다는결과를보고하였다 (Ko, Jang, & Lee, 2015). 또한외상사건을하나라도경험한대학생들중수면장애를갖고있는경우정서조절영역에서의어려움을나타냈으며 (Pickett, Barbaro, & Mello, 2016), 외상사건을경험한대학생들에서성별과외상후경과한시간을통제했음에도외상경험과흡연상태간의관계를 PTSD 증상이매개한다는결과가보고되었다 (Gabert Quillen, Selya, & Delahanty, 2015). 이외에도 5년간의종단연구를통해 PTSD 증상이없는사람보다부분및완전 PTSD를가진대학생들에게서연구기간내내더많은알코올과약물사용을보였다는선행연구가있었다 (Read et al., 2012). 이처럼외상에노출된대학생들을대상으로한선행연구결과들로미루어볼때, 외상이미치는영향력의정도가심각한것으로나타났다. 그러나, 앞서밝힌것처럼외상에노출된대학생모두가 PTSD 증상으로이어지는것은아니며, 증상을경험하더라도어떤이들은짧은시간내에 PTSD 증상이발병하여오랜기간지속되기도하고, 어떤이들은처음에는 PTSD 증상이나타나지않다가한참시간이흐른후증상이서서히나타나기도하며, 어떤이들은처음에증상이나타났다가금방사라지기도하는등조금씩차이를보인다. 그러나, 외상을경험한모든사람들이동일한경로를통해 PTSD 증상을경험하지않음에도불구하고개인간차이에대한연구와더불어대학생들을대상으로한국내 PTSD 연구자체가그리많지않음을알수있다. 한국심리학회지에대학생을대상으로한외상및 PTSD 연구는 80 여건에지나지않으며, 한국심리학회지에게재된대학생을대상으로한우울연구가 520 여건정도되는것을감안했을때이는충분히적은수임을알수있다. 이에본연구에서는대학생들을대상으로외상사건에대한노출에서 PTSD 로이어지는경로에서의심리적메커니즘과개인차및성차가존재 하는지를알아보고자한다. 먼저외상경험후 PTSD 증상에이르게되는과정에영향을줄수있는몇가지변인들을고려해볼수있는데침습적반추가이에해당한다. DSM-5 에서는 PTSD의진단기준 B로반복적, 불수의적이고, 침습적인고통스러운외상사건의기억을제시하고있으며, 이를통해반복적으로행해지는침습적인회상에대해서최근에다양한연구들이진행되어왔다. 침습적회상은크게침습적기억 (intrusive memory) 과침습적사고 (intrusive thought) 로나눠지는데 (Ehlers, Hackmann, & Michael, 2004; Speckens, Ehlers, Hackmann, Ruths, & Clark, 2007), 침습적기억은상대적으로선명하고, 감각적인양상에많이의존하며, 특히청각이나후각, 미각등다양한감각양상을보이기도하지만대체로시각적인양상이많이나타난다 (Berntsen, Willert, & Rubin, 2003). 이러한침습적기억은침습의의미에대해부적응적인평가를내리게하며자기상에위협을주기도한다 (Cheung & Bryant, 2016; Ehlers & Steil, 1995). 반면침습적사고에는외상에대한평가와반추가포함되며, 이중반추는자신에게초점이맞춰진과거부정적경험이나기분에대해반복적으로떠올려지는부정적인사고로정의된다 (Papageorgiou & Wells, 2003). Janoff-Bulman(2010) 에의하면, 외상을경험한개인은인지적이고정서적체계에서의불균형을경험하게되고, 이로써점점외상사건에몰입하게되어반복적으로외상사건에대해생각하게된다고한다. 이과정에서반복적으로외상사건이떠오르는과정을반추라고하며, 이는외상후경험하는고통스러운증상들을이해하려는일종의반응방식으로볼수있다. 사람들은반추를이용해당면한문제를해결하고, 스트레스와관련한정보를처리하려하지만아이러니하게도반추로인해부정적인정서와사고가더욱지속되고반복되는악순환을경험하게된다 (Smith & Alloy, 2009). 기존의선행연구에서는앞서설명한반추가 PTSD의발병 (Markham, & Mason, 2016; Spasojević, & Alloy, 2001) 과심각도 (Blackburn & Owens, 2016; Michael, Halligan, Clark, & Ehlers, 2007) 를예측한다고보고했으며, 또한 PTSD를지속시키는강력한예언인자일수있음을제안했다 (Ehring, Frank, & Ehlers, 2008; Zhou & Wu, 2016). 중국청소년을대상으로실시한연구에서는반추가외상경험과 PTSD를매개한다는연구결과를보고하였고 (Zhen, Quan, Yao, & Zhou, 2016), Ehlers와 Steil(1995) 은반추를통해침습을통제하려하지만오히려이러한시도가외상기억과의미를변화시키는것을막음으로써침습적회상을지속시킨다고보고하였다. 또한 Janoff-Bulman(2010) 은외상사건에서의반추가외상을입은사람의주의를부정적인외상결과로향하게하며, 이를통해부정적정서와인지를증가시키고 (Blackburn and Owens, 326

3 Moderated mediation in PTSD 2016; Stockton, Hunt, & Joseph, 2011) 마침내 PTSD를야기한다고주장하였다 (Borders et al, 2015; Chuen Yee Lo et al, 2012; Roley et al, 2015; Zhen, Quan, Yao, & Zhou, 2016). 한편, 국내연구에서 (Lee, Lee, Yun, Kim, & Choi, 2017) 는외상경험이 PTSD 증상으로이어지는경로에서침습적반추의매개효과가성차에따라달라지는것으로나타났으며, 남성은매개효과가유의하지않은데반해여성의매개효과만유의한것으로나타났다. 비슷한연구에서도남성에비해여성의반추점수가통계적으로유의하게더높았다는연구결과가보고되었다 (Jeon & Kim, 2013; Johnson & Whisman, 2013; Nolen Hoeksema, & Jackson, 2001). 이러한결과는같은외상사건을경험하더라도외상사건과반추를통해 PTSD 증상에이르게되는경로에성차가존재할수있음을의미한다. 한편, 연구자들은 PTSD와미래인지의관련성에대해주목해왔다. 이를지지하는연구결과들로, 가정폭력피해자여성들을대상으로한국내연구에서 부정적인사건이일어나리라믿는 미래사건발생가능성이 PTSD에독립적으로영향을주는지에대해서는유의한결과를발견하지는못했지만 (Lee & Cho, 2009), 미래사건발생가능성과 PTSD 증상간관련이있다는결과가외국선행연구들에서는꾸준히보고되어왔으며 (Frazier, 2003; Frazier, 2012; Hintz et al., 2010), 최근에는 PTSD와미래기억간유의한관련성이있다는외국의연구결과가보고되기도하였다 (McFarland, 2016; Scott et al., 2016). 또한외상경험전부정적미래에대한침습적인심상및사고를측정하는외상전스트레스반응체크리스트 (Pretraumatic stress reactions checklist, PreCL) 가 PTSD 증상의수준을유의하게예측했다는선행연구를고려했을때 (Berntsen & Rubin, 2015), 미래에대한인지는 PTSD를예측하는데중요한변인으로고려할필요가있을것으로생각된다. 좀더구체적으로, 외상후 PTSD 증상을가진사람들은그렇지않은사람들에비해구체적인미래긍정심상을잘떠올리지못하는경향이있는반면 (Brown et al., 2013; Kleim, Graham, Fihosy, Stott & Ehlers, 2014), 미래에일어날것으로예상하는일에대해 위협이닥쳐올것 이라는부정적인인지특성을보이는데 (Clark, 1999; Ehelrs & Clark, 2000; Llera & Newman, 2014), 이는 DSM-5 의진단기준으로제시된자신, 다른사람, 그리고세계에대한지속적이고과장된부정적예상을반영하는특성으로볼수있다. 이와같은미래에대한부정적인지를줄이는개입을하지않을경우이는부정적인침습적심상으로이어질수있으며 (Berntsen & Rubin, 2015; Szpunar, 2010), 이러한침습적심상은과거에경험했던것과유사한부정적인정서를다시불러일으키고 (Addis, Wong, & Schacter, 2007; Botzung, Denkova, & Manning, 2008; D Argembeau, 2012) 결국 PTSD 증 상에영향을줄수있다. 앞서진술한연구결과및가설들을참고할때, 부정적미래인지는매개보다는조절변인으로작용할가능성이있으며, 특히외상사건노출과침습적심상으로가는경로에부정적미래인지가조절할가능성이있을것으로추측된다. 더불어외상후스트레스장애를가진사람들을대상으로연구가진행된것은아니지만, 치료적개입을통해미래에대한부정적심상을줄이고긍정적심상을증가시키는것이우울증상을경감시키고행동활성화를증가시키는것으로보고된선행연구결과들을고려할때에도 (Blackwell & Holmes, 2017; Renner, Pictet, Holmes, & Blackwell, 2017) 미래인지를매개보다는조절변인으로설정하는것이타당한것으로생각된다. 한편, 외상노출후 PTSD 증상에이르게되는경로에서침습적반추에성차가존재한다는연구결과와유사하게외상후역기능적인지를측정하는외상후인지검사 (Posttraumatic Cognitions Inventory, PTCI) 척도에서남성보다여성이자신과세상에대한더부정적인도식을보고했다는결과들을고려할때 (Diehle, de Roos, Meiser-Stedman, Boer, & Lindauer, 2015; Hatcher, Whitaker, & Karl, 2009; Simmons & Granvold, 2005) 미래인지역시남성보다여성에서더부정적일것으로가정해볼수있다. 요약하면, 선행연구결과들을고려할때, PTSD 발병및유지, 심각도등에외상관련침습적반추와미래를인지하는방식이 PTSD 에영향을줄가능성이있으며, 전술한변인들간의관계에서성차가있을가능성에대해추측해볼수있다. 따라서본연구에서는외상경험과 PTSD 증상간관계에서침습적반추가매개역할을하는지, 그리고부정적미래인지가외상경험과의상호작용을통해침습적반추및 PTSD 증상에영향을미치는지 ( 조절된매개 ), 그리고그러한조절된매개효과에성차가있는지를조절된조절된매개모형분석을통해살펴보고자하였다. 좀더구체적으로살펴보면, 본연구는대학생을대상으로 1) 외상경험과 PTSD 증상간관계에서의외상관련반추의매개효과가부정적미래인지수준에따라조절이되는지 ( 조절된매개 ), 2) 앞서살펴본 1) 의조절된매개효과가성차에의해서도조절이되는지를조절된조절된매개효과 (moderated moderated mediation) 를통해살펴보고자하였다. 본연구에서의가설은다음과같다. 가설1. 외상경험과 PTSD 증상간의관계는침습적반추를통해매개될것이다. 가설2. 동일한외상경험을하더라도미래를덜부정적으로인지하는집단이미래를더부정적으로인지하는집단에비해침습적반추, PTSD 증상의수준이더낮을것이다. 가설3. 외상경험과침습적반추, PTSD 증상을부정적미래인지 327

4 Kim and Lee 가조절하는효과는또한성별에따라다르게나타날것이다. 본연구에서가정한모형은 Figure 1 에제시되어있다. 연구대상및자료수집절차 방법 본연구의자료는서베이몽키 ( 를통해 온라인설문조사방식으로수집되었으며, 설문참여의사를밝힌 대학생및대학원생 830 명이설문에참여하였다. 설문에들어가기 전에앞서참여자들은설문을중지하고싶다면어떠한불이익없 Negative prospective cognition Gender Trauma Intrusive rumination Figure 1. Proposed moderated moderated mediation model. PTSD symptoms 이바로설문을중지할수있음과모든개인정보가연구이외의목적으로사용되지않을것임을안내받고설문에대한동의서를작성하였다. 이중설문지에동의하지않은경우와설문지에끝까지응답하지않은 337명의자료, 과거및현재정신질환병력이있다고응답한자료및각척도별로극단치 (M±3SD의범위를벗어나는자료 ) 를보고한 103 명의자료를제외한후총 440명의자료를최종분석에사용했다. 연구참여자들의인구통계학적특성은 Table 1에제시되어있다. 설문조사에참여한사람들에게는추첨방식을통해소정의상품권이전달되었다. 측정도구생활사건체크리스트 (Life Event Checklist, LEC) Blake 등 (1995) 이개인의외상경험을측정하기위해제작했으며국내에서 Bae, Kim, Koh, Kim과 Park(2008) 이번안및타당화하였다. 이척도는 DSM-5에서외상으로규정한재난, 사고, 성폭행과강간, 포로등 17개분야의외상사건으로이루어져있으며, 제시된각사건에대해 (1) 나에게일어남, (2) 목격했음, (3) 얘기를들음, (4) 직업상경험, (5) 확실치않음, (6) 해당없음의 6점척도에단일로, 혹은중복해서응답할수있다. 원척도의경우문항 1번부터 17번 Table 1. Demographic Characteristics (N = 440) Variables Past/Present Psychiatric Diagnostic Medical History Male Female n % n % Presence Absence Total χ 2 = 4.47* Age Total χ 2 = 61.95*** M = 21.89, SD = 2.38 Region Seoul & Gyeonggi-do *p <.05. **p <.01. ***p <.001. Kangwon-do Chungcheong-do Gyeongsang-do Jeolla-do Jeju-do Total χ 2 =

5 Moderated mediation in PTSD 까지의 (1), (2), (3), (4) 의수를모두더해분석에이용하지만, 본연구에서는일반스트레스와유사하여외상사건이라고보기어려운 17번문항 ( 그밖의매우스트레스적인사건이나경험 ) 은제외하고 1번부터 16번문항의 (1), (2), (3), (4) 의수를모두더해분석에사용하였다. 원타당화연구에서의내적일관성 (Cronbach's α) 은.68이었으며, 본연구에서의내적일관성은.79였다. 사건충격척도 (Impact of the Event Scale-Revised, IES-R-K) PTSD 증상을평가하기위해 Horowitz(1979) 가개발했으며, 추가로과각성을측정하기위해 Weiss(2007) 가 IES-R로수정및보완하였고, 국내에서도신뢰도와타당도를검증하였다 (Eun et al., 2005). 총 22문항으로과각성 6문항, 회피 6문항, 침습 5문항, 수면장애및정서적마비와해리 5문항으로구성되어있으며, 지난한주간의증상심각도를 0점 ( 전혀없다 ) 에서 4점 ( 극심히있다 ) 까지 5 점리커트식척도로평가하도록되어있다. Cronbach α는 이었으며, 본연구에서의내적일관성은.95이다. 사건관련반추척도 (Event Related Rumination Inventory, ERRI) 외상사건과관련된반추반응을측정하기위해 Cann 등 (2011) 이개발했으며, 국내에서 Ahn, Joo, Min과 Sim(2013) 이타당화한질문지를사용하였다. 이척도는생활스트레스사건과관련해경험하는침습적반추 ( 생각하려하지않을때에도생각이떠오르는것 ) 10문항과의도적반추 ( 그경험에대해의도적으로생각을하려는것 ) 10문항으로구성된자기보고식검사이다. 반추의하위유형인의도적반추가외상후성장으로진행되는과정과정적관계가있다는선행연구 (Yang & Kim, 2014; Yu, 2015) 들을토대로, 본연구에서는매개변인으로침습적반추만선별하여사용하였다. 본척도는 0점 ( 전혀아니다 ) 에서 3점 ( 자주그렇다 ) 까지의 4점리커트척도로구성되어있으며, 각하위척도총점이높을수록해당하는반추유형을많이사용하는것을의미한다. Ahn, Joo, Min과 Sim(2013) 의연구에서전체척도의 Cronbach α=.94였으며각요인들의 α는.93으로모두양호했다. 본연구에서의내적일관성은.94이다. 미래인지설문지 (Prospective Cognition Questionnaire, PCQ) Miranda와 Mennin(2007) 이미래를어떤식으로인지하고있는지를측정하기위해개발한척도를임상심리전문가두명, 그리고정신보건간호사한명이각각번역, 교차검토하고이중언어사용자에게검토를마친후사용하였다. 17개의긍정문항 ( 나는많은친구들과지속적인관계를유지할것이다. ) 과 17개의부정문항 ( 나는사람들에게실패자로여겨질것이다 ) 이존재하며, 각문항의내용 이자신의미래에일어날것인지에대해예, 혹은아니오로응답하고, 예 / 아니오를얼마나확신하는지 1점에서 ( 전혀확실하지않다 ) 5 점까지 ( 매우확실하다 ) 의리커트척도로평정한다. 미래를어떤방향으로예측하느냐에따라긍정적예측과부정적예측의하위척도가존재하며, 미래에일어날것임을 매우확신 하는경우에만 1점으로채점한다. 본연구에서는부정적인질문문항에 예 로, 긍정적인질문문항에 아니오 로매우확신하여응답하는경우에만채점하였고내적일관성은.67이다. 자료분석본연구에서는통계분석을하기위해 SPSS 23.0 프로그램을이용하였다. 대학 ( 원 ) 생들의인구통계학적특성과주요변인간관계를알아보기위해기술통계분석과 Pearson 상관분석을, 그리고남녀대학생간의성차를알아보기위해 χ 2 분석및독립표본 t검증을실시했다. 또한외상경험을독립변인, PTSD 증상을종속변인, 침습적반추를매개변인, 부정적미래인지와성별을조절변인으로설정함으로써이들의관계를검증하기위해조절된조절된매개모형 (moderated moderated mediation model) 을설정하였고, 이를살펴보기위해 Hayes 가제공한 SPSS PROCESS를시행하였다. 이과정에서회귀계수의해석을용이하게하기위해평균중심화하여독립변인및조절변인을투입하였으며 (Lee, 2016), 독립변인간다중공선성이존재하는지파악하기위해 torelance와 VIF도함께확인하였다. 또한간접효과의검증을위해 bootstrapping 절차를실시하였다. 결과인구통계학적특성본연구의분석대상인남녀대학 ( 원 ) 생들의인구통계학적특성은 Table 1에제시되어있으며, 참여자들의나이에서집단간유의한차이가나타났다, χ 2 (5, N= 440) = 61.95, p<.001. 여학생집단의경우연령대전반에걸쳐응답자가많은것에비해남학생집단의경우 24세이상의응답자가압도적으로많았다. 이러한차이에서남학생의경우군복무로인한낮은참여도를유추해볼수있다. 지역에서는집단간의유의한차이가없었다, χ 2 (5, N= 440) = 2.83, ns. 각척도별기술통계치및성차각척도의기술통계치와그에관한성차를 Table 2에제시하였다. 본연구에서측정하는변인이정상분포를따르는지를확인하기위해왜도및첨도를산출한결과, 변인들의왜도와첨도의절댓값이 3과 10을넘지않아정규분포가정을충족하는것으로해석하였 329

6 Kim and Lee Table 2. Descriptive Statistics of Study Variables (N = 440) Gender N M SD t Skewness Kurtosis M SE M SE Tauma Male Female PTSD symptoms Male *** Female Intrusive rumination Male ** Female Negative prospective cognition Male Female *p <.05. **p <.01. ***p <.001. Table 3. Correlations of Study Variables by Gender (N = 440) Variables Trauma.23* PTSD symptoms.21**.71**.26** Intrusive rumination.20**.74**.32** Negative prospective cognition.04.17**.23** Note. The upper part of the diagonal is the male data, and the lower part of the diagonal is female data. *p <.05. **p <.01. ***p <.001. 다 (Kline, 2005). 또한각변인에성차가있는지알아보기위해독립표본 t검증을실시했다. PTSD 증상을제외 (Levene's test F = 6.32, p<.01) 한다른변인들에서모두등분산이가정되었으며, 외상경험과미래를부정적으로인지하는양상은남녀간에차이가없었지만, PTSD 증상과침습적반추에서는유의한성차가있었다. PTSD 증상과침습적반추의수준모두여학생집단이유의하게높은것으로나타났다. 외상경험, PTSD 증상, 침습적반추및부정적미래인지간의상관관계변인간의 Pearson 상관계수는 Table 3과같다. 대각선윗부분은남학생집단의상관관계, 아랫부분은여학생집단의상관관계이다. 남학생집단의경우외상경험은 PTSD 증상과정적상관을보였다, r =.23, p<.05. 그러나부정적미래인지, r =.02, p>.05, 침습적반추, r =.15, p>.05, 와는유의미한상관이없었다. PTSD 증상은침습적반추, r =.71, p<.01, 부정적미래인지, r =.26, p<.01, 와정적상관을보였다. 침습적반추는부정적미래인지와정적상관을보였다, r =.32, p<.01. 또한여학생집단의외상경험은 PTSD 증상, r =.21, p<.01, 침습적반추, r =.20, p<.01, 와정적상관을보였으나, 부정적미래인지, r =.04, p>.05, 와는유의미한상관이없었다. PTSD 증상은침습적반추, r =.74, p<.01, 부정적미래인지, r =.17, p<.01, 와는정적상관을보였다. 침습적반추는부정적미래인지와정적상관을보였다, r =.23, p<.01. 외상사건의경험빈도, PTSD 증상, 침습적반추, 부정적미래인지및성차의관계 : 조절된조절된매개효과검증외상사건경험빈도와 PTSD 증상간의관계에서침습적반추의매개효과가유의한지, 침습적반추의매개효과가부정적미래인지에의해조절되는지, 그리고부정적미래인지의조절된매개효과가성차에따라달라지는지를 Hayes(2015) 가제공한 SPSS PROCESS를이용하여조절된조절된매개모형분석 (Moderated moderated mediation) 을시행하였으며, 성별간유의한차이가있던나이를공변인으로설정하였다. 결과는 Table 4와 Table 5에제시되어있다. 먼저변인간다중공선성의유무를파악하기위해 tolerance와분산팽창요인 (VIF) 의값을확인한결과, 공선성통계량모두 tolerance 값이.01 보다크고, 분산팽창요인 (VIF) 값이 10보다작으므로공선성의문제가없는것으로나타나조절된조절된매개분석을계속진행하였다. 참여자들의자료를분석한결과 (Table 4), 침습적반추가결과변 330

7 Moderated mediation in PTSD Table 4. Direct Indirect Effect(s) of Trauma on PTSD Symptoms: Moderated Moderated Mediation (N = 440) Outcome: Intrusive rumination Unstandardized Coefficeints Multicollinearity t LLCI ULCI Coeff (β) SE tolerance VIF (constant) Trauma *** Negative prospective Cognition *** Gender *** Age Int_ Int_ Int_ Int_ ** Outcome: PTSD symptoms Unstandardized Coefficeints Multicollinearity t LLCI ULCI Coeff (β) SE tolerance VIF (constant) Intrusive rumination *** Trauma ** Age Direct effect of X on Y Indirect effect of X on Y Intrusive rumination Effect.32 Effect.52 SE.12 Boot SE.13 t 2.64** Boot LLCI.28 LLCI.08 Boot ULCI.78 Note. int_1 = trauma x negative prospective cognition; int_2 = trauma x gender; int_3 = negative prospective cognition x gender; int_4 = trauma x gender x negative prospective cognition; LLCI= Lower level for 95% confidence interval; ULCI= Upper level for 95% confidence interval. p <.10. *p <.05. **p <.01. ***p <.001. ULCI.56 인인모델에서, 외상사건은침습적반추를유의하게예측한것으로나타났다. PTSD 증상이결과변인인모델에서도침습적반추가 PTSD 증상을, 그리고외상사건이 PTSD 증상을여전히유의한수준에서예측한것으로나타났다. 이런결과는외상사건과 PTSD 증상간침습적반추의부분매개효과가있음을시사한다. 이는 bootstrapping 방법을이용한간접효과검증에서도확증되었다. 또한외상사건과침습적반추간의관계를부정적미래인지및성별, β=.32, p<.01, 이조절하는 3원상호작용효과가유의하게나타났다 (Hayes, 2015). 다음으로외상과 PTSD 증상간관계에서침습적반추의매개효과가부정적미래인지에의해조절되는관계가다시성별에의해조절되는지확인하기위해조절된조절된매개효과의유의성을검토하였다. 조절된조절된매개지수는간접효과와조절변수의관계를수량화한지수로, 신뢰구간이 0을포함하지않으면조절된조절된매개효과가나타났다고해석한다 (Hayes, 2015). Table 5A ( 조절된조절된매개지수 ) 를살펴보면, 신뢰구간이 0을포함하지않아조절된매 개모형의조절효과 ( 성차 ) 가유의한것으로나타났다. 이를좀더구체적으로살펴보면남녀에따라조절된매개효과가다르게나타났으며 (Table 5B), 조절된매개효과의성차는부정적미래인지수준의가장높은상위 10% 에서나타났음을알수있다 (Table 5C). 즉, 부정적미래인지의상위 10% 에서여학생의경우는매개효과가유의한것으로나타난반면, 남학생의경우는유의하지않은것으로나타났다 (Table 5D). Figure 2를보면, 여학생의경우동일한수의외상경험에노출되었더라도, 미래를더부정적으로인지하는사람들은그렇지않은사람에비해침습적반추및 PTSD 증상수준이더높아지는것을확인할수있는반면, 미래를덜부정적으로인지하는여학생들은반추및 PTSD 증상수준이낮은것을확인할수있다. 결과를도표화한 Figure 3을살펴보면, 간접효과의성차가부정적미래인지의 90th 수준에서급격히차이가나는것을확인할수있다. 즉, 여학생에서미래를부정적으로인지하는수준이높을경우외상사건의경험횟수가침습적반추를매개로 PTSD 증상에미치는영향력이큰반면에, 남학생은그렇지않은것을의미한다

8 Kim and Lee Table 5. Index of Moderated Moderated Mediation and Conditional Moderated Mediation (N = 440) A B C D Mediator Index SE (Boot) Boot LLCI Boot ULCI Intrusive rumination Moderator Mediator Gender Index SE (Boot) Boot LLCI Boot ULCI Negative Prospective Cognition Intrusive Rumination Male Moderator Mediator Negative Prospective Cognition Female Index SE (Boot) Boot LLCI Boot ULCI Gender Intrusive Rumination -.82 (10th) Mediator Gender Negetive Prospective Cognition -.82 (25th) (50th) (75th) (90th) Index SE (Boot) Boot LLCI Boot ULCI Intrusive rumination Male -.82 (10th) (25th) (50th) (75th) (90th) Female -.82 (10th) (25th) (50th) (75th) (90th) Note. Boot LLCI= Lower level of indirect effect for 95% confidence interval; Boot ULCI= Upper level of indirect effect for 95% confidence interval. 논의본연구는외상을경험한대학생들이 PTSD 증상을경험하는과정에서침습적반추와부정적미래인지가어떠한영향을미치는지, 그러한영향이성별에따라다르게나타나는지를검증하고자하였으며, 이를위해 Hayes가제공한 SPSS macro를이용해조절된조절된매개분석을실시했다. 그결과침습적반추가외상경험의빈도와 PTSD 증상간의관계를부분매개하는것으로나타났다. 또한침습적반추의부분매개효과가부정적미래인지의수준에따라달라지는조절된매개효과는남녀에따라차이가있는것으로나타났는데, 구체적으로상위 10% 의부정적미래인지수준에서남학생은조절된매개효과가유의하지않았지만여학생은조절된매개효과가유의한것으로나타났다. 이러한결과는부정적미래인지의수준에따라, 그리고성차에따라외상노출후침습적반추를통해 PTSD 증상에이르게하는영향력과심리적기제가다를수있음을시사한다. 결과를좀더구체적으로살펴보면다음과같다. 첫째, 외상이침습적반추에영향을준다는선행연구들의결과와동일하게 (Gold, & Wegner, 1995; Markham, & Mason, 2016) 외 상경험과침습적반추는정적관계가있는것으로나타났고, 또한외상경험과 PTSD 증상의관계는침습적반추를통해부분매개되는것으로나타났다. 이는중국청소년들을대상으로진행한연구에서침습적반추가외상경험과 PTSD 증상을부분매개한다는결과와일관된것이다 (Zhen, Quan, Yao, & Zhou, 2016). 한편, 이러한부분매개결과는외상경험빈도자체가 PTSD 증상에직접영향을줄수있을뿐아니라, 침습적반추의매개를통해서간접적으로도 PTSD 증상에영향을줄수있음을시사한다. 외상경험의빈도자체가 PTSD 증상에직접영향을줄수있다는결과는남아프리카청소년들을대상으로한연구에서경험한외상의빈도가많아질수록우울증상, PTSD 증상및불안증상의수준이선형적으로더높아졌다는결과 (Suliman et al., 2009), 그리고 1,824명의성인들을대상으로한연구에서다중외상경험이 PTSD의위험요인이될수있다고밝힌연구결과 (Frans, Rimmö, Åberg, & Fredrikson, 2005) 와일맥상통한다. 한편, Janoff-Bulman(2010) 은산산조각난세계가정 (The shattered world assumption) 을통해외상사건을경험하게되면기존에가지고있던자기, 타인, 세계에대한개인의핵심신념과가정이산산조각나면서, 자기, 타인, 세상에대한 332

9 Moderated mediation in PTSD Intrusive rumination Male Female Negative prospective cognition 90th 75th 0-50th Frequency of trauma A Male Female PTSD symptoms Negative prospective cognition 90th 75th 0-50th Frequency of trauma B Figure 2. Moderating effect of negative prospective cognition between frequency of trauma and (A) intrusive rumination/ (B) PTSD Symptoms. (A) & (B) of Graph 1 show gender difference of moderated mediating effect. Indirect effect of trauma th 50-75th 75-90th 90th Negative prospective cognition Gender Male Female Figure 3. Gender difference graph of moderated moderated mediation. 부정적가정이생겨나고부정적정서를경험하게된다고보고했다. 이와비슷하게 Tedeschi 와 Calhoun(2004) 도외상경험을통해이 전에가진도식이붕괴되면서인지적및정서적체계에서의불균형 을경험하게된다고설명하였는데, 이러한부정적인정서를조절하 기위한해결책으로사용되는전략이반추이며이는외상후경험하는고통스러운증상들을이해하려는일종의반응방식으로볼수있다. 그러나부정적정서를조절하려는노력으로반추를사용함에도불구하고반추하는동안, 혹은반추한후에생겨나는부정적인감정이오히려외상에대한인출단서를제공하여의도한바와달리침습적기억의수를증가시키며, 개인은이를통제하기위해다시반추를진행하는악순환에빠지게된다. 이과정에서침습적반추는고통스러운감정적경험을회피하도록만들거나이에더무디게함으로써 PTSD 증상이더유발되도록하는데기여할수있다 (Fresco, Frankel, Mennin, Turk, & Heimberg, 2002; Michael, Halligan, Clark, & Ehlers, 2007). 이처럼외상경험후나타나는침습적반추는 PTSD 증상을유발할수있는심리적기제변인중하나인것으로보이며 PTSD 증상의치료를위해서는외상사건에대한침습적이고통제되지않는부정적인사고방식을회피하거나억압하지않으면서사건을이해하도록하는방향의치료적개입이필요할것으로보인다. 또한, 외상노출후 PTSD 증상에이르는경로에서침습적반추의부분매개효과가나타난결과는침습적반추외에다른제 3의 333

10 Kim and Lee 변인이영향을미칠가능성이있음을의미한다. 가령아동기성적학대경험이정서조절의어려움을매개로 PTSD 증상에영향을줄수있다는결과가있었고 (Ullman, Peter-Hagene, & Relyea, 2014), 국내에서는외근경찰관을대상으로한연구에서외상경험이역기능적대처를매개로 PTSD 증상을악화시키는것으로나타났다 (Lee & Ji, 2010). 후속연구에서이외다른제3의변인에대한탐구적접근이필요할것으로보인다. 둘째, 남녀모두를포함한자료에서침습적반추의매개효과가부정적미래인지수준에의해조절되는효과는경향성 (β =.10, p<.10) 만존재하는것으로나타났다. 통계적으로유의한수치는아니지만이러한결과는남녀간효과의차이에서기인했을가능성이있는데, Table 5B를살펴보면조절된매개효과가남학생에서는나타나지않고여학생의자료에서만나타났음을알수있다 ( 조절된조절된매개효과 ). 이는간접효과크기에성차가있다는의미이며, Figure 3에서확인할수있듯이미래를부정적으로인지하는수준이높아질수록남녀의간접효과크기의차이에격차가점점벌어지는것을확인할수있다. Table 5C를통해, 부정적미래인지의상위 10% (90th) 에서남녀간의간접효과크기에유의한차이가있음을알수있는데, 이를통해미래를부정적으로인지하는수준이매우높은 ( 상위 10%) 남학생과여학생간외상과 PTSD 증상의관계를침습적반추가매개하는간접효과에유의한차이가있다고할수있다. Figure 2를통해남녀의차이를좀더자세히살펴보면, 여학생의경우미래에대한부정적으로생각하는경향이크면클수록침습적반추의수준도눈에띄게높아지는반면남학생의경우는동일한상황에서침습적반추의수준이그리높아지지않았다. 이렇듯본연구의조절된매개모형에서성차가나타난결과에대해몇가지가능성들을유추해볼수있다. 외상사건을경험한사람들중여성이남성에비해경험했던사건을더위협적이고, 부정적으로그리고더통제불가능한것으로지각하는경향이있었으며이는높은수준의부정적정서와관련이있는것으로나타났다 (Olff, Langeland, Draijer, & Gersons, 2007). 이는여성이남성에비해외상사건에대한인지적인처리방식에더큰영향을받을가능성을시사한다. 한편반추는부정적인정서에대한반응양식으로정의되며 (Nolen-Hoeksema, 1991) 외상사건으로인한부정적정서를다루기위해사용되는인지적책략일수있는데, 선행연구들은여성이침습적반추를더많이사용함을일관적으로보고해왔고 (Olff, Langeland, Draijer, & Gersons, 2007; Vishnevsky, Cann, Calhoun, Tedeschi, & Demakis, 2010), 본연구또한여학생이남학생에비해침습적반추의수준이유의하게높은것으로나타났다. 따라서, 남성에비해여성이외상사건에 대한반응으로미래에대한부정적예상을더많이투사할가능성이있으며, 이과정에서부정적정서를더많이경험하며이를처리하기위한인지적책략으로침습적반추를더많이사용할가능성을추측해볼수있다. 한편조절된매개효과에서의성차는외상경험후대처방식이남녀에따라다르기때문일수도있다. 청소년을대상으로한선행연구는남학생들은스트레스에대처하는방식으로운동, 문제와감정의은폐및문제무시등의대처방식을주로사용하는반면여학생들은계획적문제해결방식을많이이용한다고보고했다 (Shin & Khu, 2001), 이는여학생에비해남학생들이스트레스사건에대해몰입하여이해하고인지적으로처리하려는시도를적게하는경향이있음을추측해볼수있다. 그러나이러한추측을확증짓기위해서는후속연구에서남학생들의외상경험후대처방식과관련된조절변인들을좀더탐색해보고이를통해남학생들의트라우마관련보호변인들에대한연구가더진행될필요가있을것이다. 이외에도외상유형에따른차이때문에성차가나타났을가능성이있는데, 선행연구들은외상의빈도가아니라, 외상의유형으로성차가기인한다고설명하며 (Cortina & Kubiak, 2006; Tolin & Foa, 2006), 실제로여성들이남성에비해많이경험하는, 그리고제일많이경험하는외상은강제적인성접촉이고 (Choi, Lee, Lee, & Lee, 2015), 특히외상사건들중강간이 PTSD로이어질가능성이가장높다는선행연구가보고되었다 (Norris, 1992; Resnick, Kilpatrick, Dansky, Saunders, & Best, 1993). 본연구에서도남성은신체적폭행의경험을가장많이보고한반면 (58명/130명, 44.62%), 여성은불편한성적경험을제일많이보고했다 (122 명 /310 명, 39.35%). 조절된조절된매개효과가여학생들이경험하는외상유형과관련이있지는않은지, 후속연구에서외상의유형차이에따른인지적변인의상호작용효과와, PTSD의발현및진행에대해살펴볼필요가있을것으로생각된다. 마지막으로, 조절된매개효과가유의한여학생들의경우에, 동일한수준의외상경험을하더라도, 미래에대한부정적예측을적게할수록, 외상사건후의침습적반추및 PTSD 증상으로부터보호될수있는것으로나타났다 (Figure 2). 이에대한결과에근거하여, 반복적인외상경험을가지고있는여학생들에게미래에대한부정심상을변형하거나미래에대한긍정심상을만들어주는심상개입훈련을통해침습적반추및 PTSD 증상을경감시키는데도움이되는지추후연구를통해살펴보는것도도움이될것으로생각된다. 본연구에는몇가지제한점들이있으며추후이루어질연구에서보완되어야할것이다. 첫째로본연구가횡단적으로자료수집이이루어짐에따라특정시점에서참여자의태도는알수있었지만시 334

11 Moderated mediation in PTSD 간이지남에따라변인간의관계가어떻게변화해가는지에대해서 명확한정보를제공하는데에는한계가있었다. 차후에는시간의 흐름에따른종단적인연구를통하여더명확한데이터를얻을수 있을것이며이를통해구체적인치료접근이가능할것이다. 둘째, 연구에참여한표본이일반대학생이라는점이다. 표본이 제한적이기때문에본연구를일반모집단에일반화하기에한계가 있으며본연구의결과를일반화하기위해서는 PTSD 집단과다른 연령대를포함한다른집단에서추가적인검증이필요하다. 또한 개개인이경험한외상경험의심각도와유형의차이를고려하지않 고외상경험의빈도만고려했기때문에차후에이를포함한연구 가이루어져야할것이며특히, 본연구에서성별간경험한외상유 형에차이가나타남에따라후속연구에서는성별에따라경험한 외상유형간 PTSD 증상의메커니즘에대한차이를검증해보는 것도필요할것으로생각된다. 제한점이있음에도불구하고본연구의몇가지의의가있는데첫 째, 불안과우울에한정되어있던미래를인지하는방식에대한연 구를 PTSD 까지확장하고조절된조절된매개분석을통해위험군 에대한선별및치료적개입에대한기초정보를제공했다는점에서 의의가있다. 즉외상을경험한여학생중미래인지의부정적편향 수준이높은개인을대상으로미래관련부정적심상을줄이거나 긍정적심상을만들어가는치료적개입을통해침습적반추를줄이 고 PTSD 증상을감소시키는데도움을줄수있을것으로생각된다. 둘째, 조절된조절된매개분석을통해조절된매개효과의성차 및그에대한상세한이해를가능하게했다는점이다. 지금까지매 개효과의성차를보는연구나조절효과의성차를보는연구들은 많았지만이를한모델에서살펴볼수있는조절된매개모형의성 차를밝힌연구 ( 조절된조절된매개연구 ) 는없었던것으로파악된 다. 본연구에서의조절된조절된매개모형을통해외상과 PTSD 증상간의관계가 어떻게 ( 매개효과 ) 진행이되며이것이 언제 ( 조 절효과 ) 발생하는지, 그리고이러한일련의진행에성차가있는지 를한모형에서확인할수있었다 (Lee, 2016) 는점에서본연구의의 의가있다. References Addis, D. R., Wong, A. T., & Schacter, D. L. (2007). Remembering the past and imagining the future: Common and distinct neural substrates during event construction and elaboration. Neuropsychologia, 45, Ahn, H. N., Joo, H. S., Min, J. W., & Sim, K. S., (2013). Validation of the event related rumination inventory in a Korean population. Cognitive Behavior Therapy in Korea, 13, American Psychiatric Association. (2013). Diagnostic and satistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Bae, H., Kim, D., Koh, H., Kim, Y., & Park, J. S. (2008). Psychometric properties of the life events checklist-korean version. Psychiatry Investigation, 5, Berntsen, D., & Rubin, D. C. (2015). Pretraumatic stress reactions in soldiers deployed to Afghanistan. Clinical Psychological Science, 3, Berntsen, D., Willert, M., & Rubin, D. C. (2003). Splintered memories or vivid landmarks? Qualities and organization of traumatic memories with and without PTSD. Applied Cognitive Psychology, 17, Blackburn, L., & Owens, G. P. (2016). Rumination, resilience, and posttraumatic stress disorder symptom severity among veterans of Iraq and Afghanistan. Journal of Aggression, Maltreatment & Trauma, 25, Blackwell, S. E., & Holmes, E. A. (2017). Brightening the day with flashes of positive mental imagery: A case study of an individual with depression. Journal of Clinical Psychology, 73, Blake, D. D., Weathers, F. W., Nagy, L. M., Kaloupek, D. G., Gusman, F. D., Charney, D. S., & Keane, T. M. (1995). The development of a clinician-administered PTSD scale. Journal of Traumatic Stress, 8, Borders, A., Rothman, D. J., & McAndrew, L. M. (2015). Sleep problems may mediate associations between rumination and PTSD and depressive symptoms among OIF/OEF veterans. Psychological Trauma: Theory, Research, Practice, and Policy, 7, 76. Botzung, A., Denkova, E., & Manning, L. (2008). Experiencing past and future personal events: Functional neuroimaging evidence on the neural bases of mental time travel. Brain and Cognition, 66, Brown, A. D., Root, J. C., Romano, T. A., Chang, L. J., Bryant, R. A., & Hirst, W. (2013). Overgeneralized autobiographical memory and future thinking in combat veterans with posttraumatic stress disorder. Journal of Behavior Therapy and Experimental Psychiatry, 44, Cann, A., Calhoun, L. G., Tedeschi, R. G., Triplett, K. N., Vishnevsky, T., & Lindstrom, C. M. (2011). Assessing posttraumatic cognitive processes: The event related rumination inventory. Anxiety, Stress, & Coping, 24, Cheung, J., & Bryant, R. A. (2016). The impact of appraisals on intrusive memories. Journal of Behavior Therapy and Experimental Psychiatry, 54, Cho. Y. R. (2012). Factor structure, convergent and discriminative validity of a Korean version of the Posttraumatic Cognitions Inventory (PTCI) in a sample of traumatized undergraduates. Cognitive Behavior Therapy in Korea, 12,

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